What freediving taught me about neonatal resuscitation

This semester I am teaching a class with the theme "Exploring the Limits of the Human Body." We are currently reading Deep: Freediving, Renegade Science, and What the Ocean Tells Us About Ourselves by James Nestor. This book is a fascinating narrative that combines ocean exploration, marine biology, competitive and research freediving, and dormant human abilities that originate in our deep oceanic past (the mammalian dive reflex, magnetoreception, and echolocation).

When freedivers experience a blackout--usually near the surface at the end of their dive--they still remain responsive to sound. After pulling the unconscious freediver to the surface, the safety team will call the diver by name and tell them to breathe: "Breathe, Alexy, breathe! Breathe, Alexy, breathe!"

~~~

From my time in the home birth world, I often heard midwives talking about how they involve parents in neonatal resuscitation. A common practice is to have one of the parents speak to the baby and encourage them to breathe.

I had always categorized this practice as a nice idea. It certainly wouldn't hurt, right? In fact, I did it instinctively when Inga was born; she lost color and tone after about 30 seconds and needed mouth-to-mouth. While I was resuscitating her, I was talking to her and encouraging her to breathe.

However, I never thought that there was a scientific or physiologic reason for calling the baby by name and telling them to breathe--until I learned about freediving. Even when all of their other senses are offline, a blacked-out freediver will still respond to sound.

~~~

Calling a baby by name and telling them to breathe, especially when done by a familiar voice, isn't just fluffy woo-woo. It's part of our basic physiology.

This was a lesson in giving more respect to the instinctual or "homespun" practices that have evolved with midwifery and home birth. How many other traditions have yet-to-be-discovered science behind them?

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10 mechanisms of upright physiological breech birth

This short video shows 10 key mechanisms of a normal upright breech birth.

1. Buttocks/feet emerge sacrum-transverse
2. Body restitutes to sacrum-anterior as trunk is born
3. Legs release spontaneously
4. “Cleavage” indicates arms are not behind head
5. Baby does tummy crunches to bring down arms & flex head
6. Arms release spontaneously
7. Full perineum = head is flexed
8. Head releases spontaneously
9. Baby passed to mother
10. Cord left intact even if resuscitation is needed

When these mechanisms are present, there's no need to do anything other than catch the baby. Approximately 70% of upright breech births will occur spontaneously with no need for any hands-on maneuvers. See Louwen 2017 for more information.



The original footage is taken from a longer video of a Brazilian couple whose planned homebirth ended up at a hospital due to breech presentation. I wrote about it several months ago here.

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Michel Odent on breech

Whenever I pull Michel Odent's book Birth Reborn off the shelf, it feels like phoning a dear friend after a long absence. We catch up on life and I remember why I enjoy this person so much.

Michel Odent is a French surgeon and obstetrician who was in charge of the Pithiviers Maternity Unit for over 20 years. At a time when cesarean rates were rising and births in France were highly medicalized, Odent turned the maternity wing at his state hospital into a haven for undisturbed, physiological birth. Most of his changes were low-cost and low-tech: creating an environment in which women were private and completely undisturbed during labor. He replaced delivery tables with big, low mattresses and cushions, birth pools, and simple furniture to aid spontaneous movement. His maternity unit had a 6-7% cesarean rate during the 1970s and 80s, even though it accepted an unscreened population.

I just opened Birth Reborn after a good year or two and turned to a section on breech birth. In his words and photos (pages 103-105 in the 2nd edition):

~~~~~

Finally, within the realm of labor and birth, one quickly learns to expect the unexpected. Sometimes a woman will have a quick and easy labor when professionals believed only a cesarean was possible. For example, women who have previously had a cesarean are sometimes told that they will always give birth that way. Yet at our clinic, one out of two women who have previously had cesareans succeed in giving birth vaginally. Nor do breech deliveries always justify the operation, although this has, nevertheless, become almost the rule in many conventional hospitals. From our experience with breech babies, we have found that by observing the natural progression of first-stage labor, we will get the best indication of what to expect at the last moment. This means we do nothing that will interfere with first-stage labor: no Pitocin, no bathing in the pool, no mention of the word "breech." If all goes smoothly, we have reason to believe the second stage of labor will not pose any problems. Our only intervention will be to insist on the supported squatting position for delivery, since it is the most mechanically efficient. It reduces the likelihood of our having to pull the baby out and is the best way to minimize the delay between the delivery of the baby's umbilicus and the baby's head, which could result in the compression of the cord and deprive the infant of oxygen. We would never risk a breech delivery with the mother in a dorsal or semi-seated position.

If, on the other hand, contractions in the first-stage labor are painful and inefficient and dilation does not progress, we must quickly dispense with the idea of vaginal delivery. Otherwise we face the danger of a last-minute "point of no return" when, after the emergence of the baby's buttocks, it is too late to switch strategies and decide on a cesarean. However, although we always perform cesareans when first-stage labor is difficult and the situation is not improving, most breech births in our clinic do end up as vaginal deliveries.

Here is a brief video of a breech birth at Pithiviers. Notice that the baby does not rotate to sacrum-anterior after the trunk is born (the most likely culprit is a nuchal arm). Odent steps in right away and frees the arm. The baby is born very quickly.

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A physiological breech birth in Brazil

This gorgeous upright breech birth is worth the time to watch. The mama had originally planned a home birth, but transferred in labor to a hospital due to breech presentation. I loved watching the OB's face as she is sitting at the foot of the bed. I imagine she is thinking "Best. Day. Ever!!!"

For a faster sneak preview, start the player at 6:15. You'll see the baby following all the cardinal movements of an upright breech:

• Body rotates from transverse to facing straight towards the attendant ("tum to bum" as they say in the UK)
• Legs go on forever, knees look turned almost inside-out, and then plop out 
• Chest crease or "cleavage" indicates arms will soon follow
• Baby does a tummy tuck once to release its arms and once again to flex its head

This all happens so quickly that the filmmaker put the birth in slow motion.



Here is the Google Translate version of the birth, taken from the YouTube page:

Thayla was born on a rainy Sunday in May 2017. The initial plan was a home birth, but she was breech (with her butt down and her head up), so it was recommended that she be born in a hospital. The family stayed at home accompanied by midwives Paula Leal and Silvia Briani of Mamatoto team and doula Thais Olardi, until her mother, Thais, was 7 cm dilated. In this hour they went to the Hospital and Maternidade Sepaco where, after a short time, Thayla was born in a totally natural way, without any intervention, in a respectful and humanized way. In the hospital the family received the support of the obstetrician Camila Escudeiro and the neonatal pediatrician Nicole Martin.

It is with great generosity that the family opens up their intimacy and discloses the video of the birth of Thayla. Parents believe that good stories deserve to be told and that it is indeed possible for pelvic babies to be born naturally. The biggest message that Thais leaves to all mothers is: "Believe in yourself, believe in the strength and perfection of your bodies!"

Clareou Films took great pleasure in following this story and is flattered to share with you a story of faith, determination and a beautiful happy ending!

Congratulations to the dads and thank you for sharing this special moment in your life with other families! Welcome, Thayla

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The Vermelin method of vaginal breech birth

While translating this French article about nonfrank breech birth, I came across a reference to the "Vermelin method" of breech delivery. The author referred to Vermelin as if it were common knowledge--and it is, apparently, in the French obstetrical tradition. I found three theses from French-speaking midwifery or medical students that explained the Vermelin method.

In 2010, Jennifer Thomé wrote a thesis (PDF) as part of her midwifery degree from the Ecole des Sage-Femmes de Bourg en Bresse. She wrote:

Vermelin's non-interventionist method
Expulsion then takes place through uterine contractions and maternal expulsive efforts.

The operator attends the physiological delivery as described above and plays the role of "attentive observer," ensuring that dystocia does not occur. See appendices I and II.

A hard surface is placed under the perineum to receive the fetus.

The practitioner can pull down a loop of cord as soon as the abdomen has emerged and perform a Bracht maneuver to assist the expulsion of the fetal head, preceded or not by a Lovset maneuver (Lansac 2006). (p. 13-14)

France takes part in the approach of not using any systematic prophylactic maneuvers but instead resorts to them in cases of dystocia (DuBois 1990). For Bracht in 1938, "the number and the precocity of interventions" during the birth of the breech was the cause of the high fetal mortality rate; he therefore advocated abstention from maneuvers and promoted spontaneous emergence of the fetus for as long as possible. In 1948, continuing Bracht's advocacy, professors Vermelin and Ribon of Nancy also advocated spontaneous breech birth, showing that childbirth can take place entirely spontaneously; the hands-off "Vermelin method" was fairly widely adopted. (p. 17)

Appendix I: Spontaneous birth of the frank breech. 

Appendix II: Spontaneous birth of the nonfrank breech

Both illustrations are from Lansac J, Body G, Perrotin F, Marret H. 

Pratique de l'accouchement, 3ème éd éditions Masson, mai 2001.

In 2011, Marie Moncollin of the University Henri Poincaré in Nancy wrote a thesis (PDF) for her MD degree. She largely echoed the same points in Thomé's thesis.

At the beginning of the 20th century, most authors considered the breech presentation to necessitate obstetric intervention: prophylactic lowering of the foot, full extraction or release of the arms as promoted by Lovset in 1937. In 1938, Bracht reacted to this attitude and advocated abstention until expulsion. He then presented his maneuver for freeing the head, which we shall discuss later.

In 1948, the authors Vermelin and Ribon of Nancy defended an even more absolute abstention from obstetrical maneuvers. For Professor Vermelin it was important not to see pathology where it did not exist. While breech delivery was considered abnormal, even obstructed, at the time, Professor Vermelin wanted to show that a breech delivery could unfold in its entirety without intervening at all. He demonstrated that Mauriceau's maneuver, apparently innocuous, could be the starting point of cerebro-meningeal lesions, neonatal death factors, or psychomotor sequelae, and that it was better to do without the maneuvers. Thus Vermelin's technique of spontaneous delivery of the breech remains a classic for obstetricians of the Ecole de Nancy (see Vermelin 1956). (p. 28)

We have seen that the School of Nancy was marked by the Vermelin technique for the birth of the breech (he was a professor at the Maternité de Nancy from 1943 to 1961), but what about 50 years later? (p. 67)

Moncollin notes that French obstetricians today are not as hands-off as Vermelin advocated for; they generally assist with the birth of the arms and the head:

The birth of the breech according to Vermelin (1948) consisted of complete abstention from maneuvers. Thus, no maneuvers were practiced. However, to prevent asphyxia in the fetus, it is now advisable to finish the delivery, when the point of the shoulder blades appears in the vulva, by releasing the arms that are in the vagina and then the head. The Lovset (1937) maneuver will facilitate the expulsion of the shoulders, then the Bracht (1938) or Mauriceau (1668) maneuvers will free the fetal head. (p. 53)

She also makes this comment about breech birth at home:

Home birth:
Do not touch the breech presentation if obstetric maneuvers are not perfectly known. In this case, it is advisable to adopt the Vermelin maneuver. (p. 66)

Finally, a 2015 MD thesis by Daouda Aliou Kone (PDF) repeats the same information about Vermelin found in the other two theses.


References:

• Dubois J, Grall J-Y. Histoire contemporaine de l’accouchement par le siège. Rev. Fr. Gynecol. Obstet, 1990; 85(5): 336-341.
• Kone DA. Etude épidémio-clinique et pronostique des accouchements par le siège dans le centre de santé de référence de la communie II du district de Bamako. Thèse pour le Docteur en Médicine. Université des sciences, des techniques et des technologies de Bamako. Faculté de médecine et d’odonto-stomatologie. 6 Jan 2015.
• Lansac J, Marret H, Oury J-F. Pratique de l'accouchement, 4ème édition, Paris, Masson 2006 553p: pp 125.
• Moncollin MM. Choix de la voie d’accouchement en cas de présentation du siège: évaluation des pratiques cliniques à la Maternité Régionale de Nancy en 2008. Thèse pour le Docteur en Médecine. Université Henri Poincaré, Faculté de Médecine de Nancy. 11 Oct 2011.
• Thomé J. La présentation du siège unique à terme: enquête sur les politiques de prise en charge des maternités du réseau AURORE. Université Claude Bernard Lyon 1, Faculté de Médecine Rockefeller, École de Sages-femmes de Bourg en Bresse. 2010.
• Vermelin H, Ribon M, Facq J. Présentation du siège complet avec déflexion primitive de la tête; dégagement spontané en occipito-postérieure. Gynecol. Obstet. 1948; 47: 1250-1253.
• Vermelin H. [The teaching and practice of the gynecology and obstetrics specialty] [Article in Spanish]. Tokoginecol Pract. 1956 Oct 15 (145): 569-81.

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Obstetric Blinders: Cord Clamping

In my last post on obstetric blinders, I quoted a 1970 article that discussed upright birth among the Bantu and Polynesian people. That article quoted M.C Botha's 1968 article on the management of the umbilical cord in labor from the South African Medical Journal. (Full text here.)

I managed to track it down and was blown away by what I found--both by the evidence against cord clamping and by the obstetric blinders that Botha wore.

Botha's article begins with some quaint observations about childbirth in the Bible and other ancient literature. Botha then examines "primitive" birthing practices:

The most primitive of the Bantu people believe that it is completely wrong to touch the cord until the whole placenta is expelled. Once bearing-down pains commence, the parturient woman sits on her haunches, as if in defaecation. The trunk is bent forward, thus increasing the intra-abdominal pressure. Her bearing-down efforts are not new to her, since she has repeated the same act in defaecation daily since she was born.

Once the baby is born, the woman (Fig. 1) will remain in a squatting position watching her new baby. The placenta delivers itself from the vagina without any maternal effort (Figs. 2 and 3). Once the placenta is delivered, by gravity, the membranes usually remain in the vagina. The patient then lifts herself on her haunches and the membranes fall out. Only now does she pay attention to the cord (Fig. 4).

Hooten [1 sic] reported the same observations. Vardi [2], on account of this observation by Hooten, investigated the extra amount of blood that can be transfused into the baby by gravity; the residual blood in the placenta was approximately 11.2 ml. By bleeding the cord the total average blood volume was 100 ml. They thus concluded that by gravity, and not clamping the cord, the baby gets an extra 89 ml. of blood. This is exactly what happens in the Bantu baby.

Working among the Bantu for 10 years, attending 26,000 Bantu and seeing only abnormal cases, I found many other complications, but a retained placenta was seldom seen. If called to a case, I usually found that the terminal part only of the membranes was still in the vagina, and had merely to be lifted out. Blood transfusion for a postpartum haemorrhage was never necessary.

It gets more interesting. In the next paragraph, Bantu writes:

In accordance with this observation, the third stage of labour in White patients was managed with the use of Syntometrine [Pitocin], letting the cord bleed, and the Brandt-Andrews manoeuvre, and in 800 cases over the past 10 years no retained placenta or postpartum haemorrhage needing blood transfusion has been found. 

Note the difference in care between Bantu women (cord left intact) and White women (oxytocics, managed 3rd stage, cord clamped on the baby's side and left to bleed on the maternal side). Bantu babies also received an "extra" 90 ml of blood compared to White babies.

Let's see what else this article has to offer. I'm going to skip the next section on the history of cord clamping from the 16th century to the present. It's worth reading on your own, however.

Next, Botha discusses a study he conducted on a consecutive series of 60 unselected women, 30 with clamped cords and 30 intact cords. In both groups, "the uterus was not handled after the birth of the baby. The placenta was not handled until the mother felt the urge to bear down herself and was only received when it appeared outside the vagina. No oxytocic drugs were used." Women with intact cords birthed their placentas much more quickly and with much lower blood loss, compared to women whose cords were clamped.

Botha did another study in which he injected dye into the placenta immediately postpartum via the umbilical vein and took a series of X-rays to visualize the descent and birth of the placenta. He found that placentas with unclamped cords delivered more quickly than placentas with clamped cords.

Let's go to the end of the article, now, in which Botha discusses his findings. He begins with an unsurprising observation: "In the cases where the cord was not clamped in the third stage there was a statistically significant difference in duration and blood loss compared with those where the cord remained clamped."

Further down, he notes that an upright maternal position helps the placenta birth rapidly and with little resistance:

As there is fundal dominance in uterine activity, the placenta is forced in the direction of least resistance towards the lower segment and vagina. If the cord is bled, this process is so rapid that retraction has not yet taken place in the cervix, and the placenta, reduced in size, is expelled without resistance into the vagina. If the patient is sitting on her haunches, it will fall out by gravity.

Skipping ahead a bit more:

If the cord is clamped, counter-resistance from the placenta may be so great that retraction may come to an end. The placenta will then be separated by retroplacental blood, which, in my opinion, is not normal but abnormal. this takes place slowly and by the time the placenta is separated the cervical muscle has also retracted. The placenta is bulky, due to the blood it contains, and expulsion is difficult. If expulsion is not possible, the inevitable result is that in a certain percentage of cases the placenta will be retained, with associated postpartum hemorrhage.

Botha notes several times that the baby receives an "extra" 90 ml of blood if the cord is left intact. (I suggest phrasing it in the inverse: when the cord is clamped, the baby loses 90 ml of blood.) His next paragraph again mentions the difference in blood received by the baby:

If the cord is not clamped until the placenta is expelled, the baby will receive an extra amount of blood, which is approximately 90 ml., as reported by Vardi. 

He also notes that Rh- sensitization is rare when the cord is left intact and the placenta is birthed spontaneously.

The conclusion is fascinating--and disturbing--in how firmly Botha's obstetric blinders were in place. I had expected his conclusion would recommend leaving the umbilical cord intact until the placenta is birthed. This would both reduce both retained placenta and postpartum hemorrhage and give the baby its full blood volume. But instead, Botha recommends a surprisingly complicated method of third stage management:

Ironically, midwives would be giving superior care by simply leaving the cord intact and waiting for the birth of the placenta, because the baby would also retain 90 ml of blood in the process.

This is a classic example of how "modern" obstetrics pursues an invasive and complex solution (oxytocic drugs, bleeding the placenta, removing the placenta with controlled traction and pressure on the uterus) while discarding the simpler, better solution (leaving the cord intact and waiting for the placenta to birth on it own)--even though the "primitive" solution is easier for the attendant and better for the baby. 

References

1. Hooton, Earnest A. Man's Poor Relations. 1st ed. New York: Doubleday, 1942. p. 412. (Corrected from the original)
2. Várdi, P.: Placental transfusion: an attempt at physiological delivery. Lancet 2:12–13, 1965.

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Anke Reitter: Setting up a breech service in Sachsenhausen Hospital, Frankfurt

Anke Reitter 

Setting up a Breech Service in Sachsenhausen Hospital, Frankfurt

North of England Breech Conference, Sheffield

Day 2

This is the second of 3 hospitals presenting about starting a vaginal breech service. The other hospitals include the Oxford Breech Clinic and The Jessop Wing in Sheffield.

Dr. Anke Reitter is a Maternal-Fetal Medicine specialist and a Fellow of the Royal College of Obstetricians and Gynaecologists. She currently directs the maternity department at the Sachsenhausen Hospital in Frankfurt. Anke did her obstetrics residency in the UK 20 years ago, which is why she is a FRCOG.

Anke agrees with Anita Hedditch’s recommendations for setting up a breech service. It sounds so logical and easy to set up a breech team, but in real life it is much harder. For the past two years Anke has been a consultant obstetrician and MFM specialist at her new hospital, and every day is a new challenge. She didn’t just start up a breech service; she was also building up her own obstetric unit.

When Anke came to Sachsenhausen in October 2014, it was a small teaching hospital doing only 800 births/year. Over the past two years, her unit has undergone many changes. Besides adding a breech service, Anke has opened a perinatal medicine department and offered high-risk pregnancy care. Her own team is comprised of two Senior Registrars and two Junior Doctors. There is no pediatric unit on site.

Her hospital's birth numbers have been going up. In 2016 they had 1,113 births, compared to 835 in 2014. The number of breech births also rose, from 30 in 2014 to 71 in 2016. Over that same time period, their cesarean rate has decreased from 36.6% to 23.6%, while the instrumental delivery rate has increased from 3.8% to 6.6%, since she uses forceps.

She urged providers and hospitals to record and share their own data. Even if you don’t have a large number of breech births, it’s important to share your outcomes with women.

Setting up a Breech Clinic
Setting up a breech clinic requires the involvement of all members of the birth team: midwives, physicians, and other medical professionals such as nurses and pediatric staff. You will need to collect and provide high-quality, consistent information. As you develop your unit's guidelines, consult other breech centers to see which guidelines they follow.

Your staff will need regular skills and drills training. Anke feels that it is wrong to put vaginal breech birth as part of an emergency obstetrics training day. It should be taught separately as a normal skill, not an emergency skill. Doing skills and drills is very important for breech--and also great fun. Anke has convinced some her team of this. They now enjoy playing around with the obstetric training models. They videotape simulated births and have become more relaxed with being filmed and with sharing and debriefing how the simulations went.

As the pregnant woman nears the end of her pregnancy, Anke's unit does an ultrasound to estimate the fetal weight, determine the type of breech presentation, and detect fetal anomalies. This last step is very important. Anke told a few stories of doing her own scans while counseling women with breech babies. She has discovered abnormalities that the women's own doctors hadn’t detected despite multiple scans.

The woman also needs informed consent. This process requires time--they schedule 30 minutes for the first consultation--and usually more than one visit. They provide written information to the woman, both their own guidelines and published guidelines. Their unit has a checklist to ensure comprehensive counseling for every woman and to document that all of the above steps were completed.

Anke's breech clinic offers the whole range of options: ECV, vaginal breech birth, and planned cesarean. External cephalic versions are done in the labor ward starting at 37 weeks. They use 250 ug s.c. of Terbutaline and do CTG before and after the ECV. The women go home the same day as the procedure. In the literature, ECVs have a 50% success rate with a 2% rate of complications and 2% of babies turning back breech. Their unit has a 60-70% success rate with ECV. She does the ECV together with a skilled Turkish colleague.

Primips, including multips who have not given birth vaginally, are given an MRI scan. The RCOG's Greentop Guidelines say that the evidence for MRI scans is unclear. Anke comes from the Frankfurt school, where primips have routine MRIs. They exclude around 20% of primips for vaginal breech birth based on their obstetric conjugates.

For planned cesarean sections, Anke's unit waits for labor to start on its own before doing the surgery. She noted that this will increase the rate of after-hours unplanned cesareans.

You will want to start by offering vaginal birth to the "easy" candidates: a baby with a flexed or neutral head, a baby that is not too big (under 3800g) and not too small (<= 10th percentile), no footling or kneeling presentations, and no prenatal fetal compromise. There are many unanswered questions about VBB: amniotic fluid levels, parity, provider experience level, frank vs. complete/incomplete presentation, and how to correctly choose the woman.

Advantages, disadvantages, and words of advice
Providing a breech service opens the door to physiological birth and to upright birth positions. Providers need to "respect the mechanism" of vaginal breech birth.

Offering a breech service can also make your obstetric service more attractive to women; Anke's unit has witnessed this first-hand as their numbers have nearly doubled since 2014. On the down side, a breech service means a higher work load and more staff needed to fulfill all the expectations (counseling, 24/7 provider availability, staffing for more unscheduled cesareans).

Setting up a breech service involves a learning curve and requires that everyone in the team is on-board. It takes time; be patient and allow things to grow. And most importantly, enjoy the opportunity to offer breech birth!

Research backing up your practice is important. Anke referred to the 2017 Frankfurt study on upright breech birth authored by Frank Louwen, Betty-Anne Daviss, Kenneth C. Johnson, and herself. It is the first study with a large cohort of vaginal breech births in the upright position, and it compares both upright and dorsal breech births. The Frankfurt study has introduced a new understanding of the cardinal movements of the breech and new maneuvers to resolve problems. Unlike large registry studies, this study had detailed information about each birth, making thorough assessment and comparison possible.

Anke worked at Dr. Louwen's Frankfurt clinic before coming to Sachsenhausen, so she knows that approach firsthand. Even in that hospital, where vaginal breech was considered safe and common, half of the planned cesareans for breech were at the mother's request. This indicates an ongoing perception among women that breech is unsafe. She lamented that most of the research on breech has compared cesarean with women delivering vaginally on their backs.

Anke stressed the importance of a "complex normality" paradigm, which recognizes the largely successful physiological process of a breech birth as "normal," but requiring unique skills and experiences. She references the following publications:

• Walker S, Scammel M, Parker P. Principles of physiological breech birth practice: A Delphi study. Midwifery. Dec 2016; 43: 1-6. 
• Evans J. Understanding physiological breech birth. Essentially MIDIRS. Feb 2012. (PDF)
• Walker S. Breech birth: An unusual normal. Pract Midwife Mar 2012; 15(3): 18,20-21.

In order to create a sustainable solution to breech, health professionals need to learn to "tolerate uncertainty" rather than trying to eliminate it. (See Simpkin AL and Schwartzstein RM. Tolerating uncertainty--the next medical revolution? NEJM 2016)

Vaginal breech birth can be a tremendous learning opportunity for providers. At the 11th Annual Normal Birth Conference in Sydney 2016, obstetrician Andrew Bisits commented, "Every breech birth was a goldmine of learning about normal birth."

Looking to the future
We have not finished learning. We need to continue to connect high quality care with physiological breech birth. We need to review our critical outcomes and create a national/international expert board. We should also collect more breech data internationally. We need to get the younger generations of midwives and OBs leading the charge because the older ones are burning out.

~~~~~

Dr. Andrea Galimberti commented that it's always interesting to see the differences in practice abroad. It is challenging to see things outside your own comfort zone.

Reviewed by Anke Reitter May 28, 2017. 

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Rebekka Visser: Guidelines and Realities, Dreams and Controversies

First International Breech Conference, Day 1

Rebekka Visser

Guidelines and Realities, Dreams and Controversies

A Dutch midwife from Usquert, Rebekka Visser is an advocate for women who want hands-off, self-directed breech births. Her midwifery practice is called Springtij.

In lieu of posting a summary of Rebekka's remarks, I will direct you to her blog, where she posted her presentation: "Let's Look Beyond Our Fishbowl."

At the end of Rebekka's lecture, an audience member asked other attendees about how breech skills are taught in their locations. Is breech taught as an emergency procedure? Or is it taught as a normal birth skill?

We had responses from many other audience members. I remember hearing someone comment that when breech is taught as an emergency skill, the rate of vaginal breech birth in a maternity unit actually goes down. This emphasizes the importance of teaching breech as part of normal birth skills, rather than labeling it as an "emergency."

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Two must-read pieces on physiology and "pronurturance"

Understanding and promoting physiology in childbirth has been an interest of mine since my graduate school years. See, for example, my one of my comprehensive exams that asked me to reflect on the intersection of childbirth and environmentalism, in which I explored biodynamic approaches to both our natural and our maternal environments.

I want to share two fascinating pieces that make a case for respecting and facilitating the hormonal physiology of childbirth, with the end goal of healthier mother-baby pairs:

The first is the article "Hormonal Physiology of Childbearing, an Essential Framework for Maternal–Newborn Nursing" by Carol Sakala, Amy M. Romano, and Sarah J. Buckley (JOGNN 45.2 264-275). From the abstract:

Knowledge of the hormonal physiology of childbearing is foundational for all who care for childbearing women and newborns. When promoted, supported, and protected, innate, hormonally driven processes optimize labor and birth, maternal and newborn transitions, breastfeeding, and mother–infant attachment. Many common perinatal interventions can interfere with or limit hormonal processes and have other unintended effects. Such interventions should only be used when clearly indicated. High-quality care incorporates salutogenic nursing practices that support physiologic processes and maternal–newborn health.

The second is a PhD thesis by Florence Anne Saxton of Southern Cross University: Pronurturance at birth and risk of postpartum haemorrhage: biology, theory and new evidence. (PDF here) From the abstract:

Background: In spite of the almost universal adoption of the active management of the 3rd stage of labour, postpartum haemorrhage (PPH) rates continue to rise; reaching 19% or more in some obstetric units. Conversely, there is emerging evidence that women who experience continuity of midwifery care have lower rates of PPH. Continuity of midwifery care normally includes immediate skin-to-skin contact and early breastfeeding in the 3rd and 4th stages of labour to optimise release of endogenous oxytocin. The objective was to determine if skin-to-skin contact and breastfeeding at birth affected the rate of early PPH in a group of mixed risk Australian women.
Method: De-identified birth records (N=11,219) for the calendar years 2009 and 2010 were extracted from the electronic ObstetriX database which records public sector births in New South Wales, Australia. Excluded (n = 3,671) were all cases where skin-to-skin and breastfeeding immediately after birth was not possible leaving 7,548 cases for analysis. The outcome measure was PPH of 500 ml or more; the independent variables were ‘skin-to-skin contact’ and ‘breastfeeding’ at birth (the combination of these two variables I ultimately termed pronurturance). Analyses were conducted to determine the risk of PPH for women who experienced skin-to-skin contact and breastfeeding at birth in the 3rd and 4th stages of labour compared with those women who did not (regardless of the woman’s risk status or mode of birth).
Results: Women who experienced skin-to-skin contact and breastfeeding at birth had an almost fourfold decrease in risk of PPH, (OR 0.26, 95% CI 0.20-0.33, p < 0.001). After adjustment for covariates women who experienced skin-to-skin contact and breastfeeding at birth were again less likely to have a PPH (OR 0.55, 95% CI 0.41-0.72, p < 0.001). This protective effect of ‘pronurturance’ on PPH held true in sub-analyses for both women at ‘lower’ risk (OR 0.22, 95% CI 0.17-0.30, p < 0.001) and ‘higher’ risk (OR 0.37, 95% CI 0.24-0.57, p < 0.001) of PPH.
Conclusion: These results suggest that skin-to-skin contact and breastfeeding in 3rd and 4th stages of labour was effective in reducing the risk of PPH in a group of mixed risk Australian women. The explanation of this finding is that skin-to-skin contact and breastfeeding promote optimal endogenous oxytocin release. Skin-to-skin contact and breastfeeding at birth has shown no known negative effects and should be encouraged for all women during 3rd and 4th stage labour care.

Here are some core elements of a physiological labor & birth

Mother moves freely & chooses her positions during labor

Quiet, private environment

Unobtrusive birth attendants

Spontaneous, mother-directed pushing and upright maternal positioning

Immediate & prolonged skin-to-skin contact

Still skin-to-skin, even when moving from tub to bed

Skin-to-skin and breastfeeding ad infinitum

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Two must-reads and some (slightly) relevant puppy cuteness

Okay, serious things first: two must-read pieces.

The first is a fantastic writeup about the hormonal physiology of childbearing, written by Carol Sakala, Amy Romano, and Dr. Sarah J. Buckley. It's written for L&D nurses and gives specific suggestions for how to "promote, support, and protect" hormonal physiology in order to "optimize labor and birth, maternal and newborn transitions, breastfeeding, and mother–infant attachment." There are 1.9 CNE units offered via AWHONN, free for the next 50 days.

The next is a series of photos of an upright vaginal breech home birth, with fantastic explanations by the birth photographer. This is one of the best photo series of a VBB that I have come across: you can see the baby working himself out, step by step!

And last...some fluff. Watch a mama dog be reunited with her puppies. I love how they start crowding around to nurse within just a few moments. I had a moment of this myself today, when Eric and I came home after being away for 8 days at a conference. It was the first time we'd ever left all the kids.

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Physiological Breech Birth: Heads Up! Breech Conference

Day 1:

Jane Evans

Physiological Breech Birth

Jane Evans's presentation was a shortened version of her "A Day At the Breech" workshops. I was able to film her presentation, but not the accompanying slides or videos. Jane also gave a shorter presentation about the cardinal movements of the breech baby on day 2.
 
UK midwife Jane Evans began by outlining the prenatal discussions and informed consent process she goes through with her clients. She wants everyone to make the right decision for that baby and that woman at that time. Today’s presentation was about the full-term, normal sized baby; it doesn’t apply to premature babies.

She has noticed that breech babies more often have a battledore insertion of the placenta. When you’re thinking about ECV and VBB, there’s so much we still don’t know.

Aims of this session:

• Feel confident that many women are able to give birth to their babies, even if it’s in an unusual position
• Have a clear understanding of the mechanisms and the path through the pelvis that the breech presenting baby takes

If you can keep the normal mechanisms in your mind, you’ll be able to pick up on the small, subtle differences.

Causes of breech presentation (3-4% of term babies will be breech)

• Gestational causes
• Fetal causes. About 6% of head-first babies have some sort of anomaly; 10% of breech do. There might be some neurological difference that predisposed a baby to breech.
• Maternal causes: placental location, fibroid, etc.

Physiological breech birth

• Spontaneous onset of labor at or around term (37th-42nd week). No induction or augmentation.
• Labor progresses well; contractions come oftener, last longer, get stronger. In the view of the woman, they come too often, last too long, and are too strong!
• The presenting part descends in the birth canal, accompanied by effacement and dilation of the cervix. As long as this is happening, at whatever speed, the outlook for a VBB looks good. Labor typically takes 6-8 hours for a primip breech—shorter than typical for a head-down baby. A stop-start labor is less likely to end in a VBB. She tries to observe without putting her hands inside the woman.
• During 2nd stage, the baby descends in the birth canal and is born by the expulsive efforts of the mother and baby, without traction from the attending practitioner.

Descent into the pelvis
The most common, most optimal position for breech baby prenatally is RSA. Frank breech most common for primips. Complete breech is more common for multips. As labor starts, the baby descends RSA through the widest part of the pelvic inlet. In a good-sized baby, if the bottom goes through spontaneously, the head should come through. The baby’s bottom drops into the pelvis and is guided by the pelvic floor muscles to rotate to RS Lateral. This is what you see when the baby is rumping. You might see lots of meconium; don’t be surprised or alarmed. The mom will often drop her bottom down to the floor and help drop the baby down. Usually you see the anterior buttock first, then the posterior buttock. Don’t wipe any maternal feces away; it causes the woman to clench up. You don’t want that to happen, especially in a breech labor.

Rumping and birthing the legs
Carefully observe the baby’s color and tone, although it’s not always reliable. At or soon after rumping, the baby will rotate back to RSA. At this point, the shoulders are coming into the widest diameter of the pelvic brim. When the baby is out to the knee pits, the baby extends its pelvis (arches its back / extends its pelvis backwards) around the maternal symphysis pubis. That’s what makes the knees look like they’re inside out. This movement helps release the legs. The baby’s head naturally tilts back as it goes past the maternal sacral prominence. The legs will look like they’re going on forever!

She’s observed that knee presentations tend to come down posterior, rather than anterior.

She pointed out the Rhombus of Michaelis (more info on its role here), which is easy to see when a woman is upright. If a woman is sitting, it presses the sacrum inward. Anatomically, it makes a breech birth more difficult.

She’s cut one 1 episiotomy for a head-down baby and 2 for breech in the past 30 years.

Birthing the arms
Once the legs are out, the baby should be direct SA. The baby continues to rotate. It does its own Lovsett maneuver and rotates from SA to Sacrum Lateral. By doing that movement through the pelvic floor, that does its own Lovsett and brings out the first arm. The second arm usually slides out. As the shoulders are coming out, the head comes into the pelvis. The occiput has rotated and is coming onto the left side.

Flexing and birthing the head
The baby comes into the pelvis and down and restitutes. The baby does a stomach scrunch and lifts its arms and legs, serving to flex its chin to its chest. This puts the baby’s head nicely into the pelvis and rolls the occiput on the internal aspect of mother’s symphisis pubis. Women report a “funny” or “peculiar” feeling and have to move, dropping forwards. This rotates the sacrum around the baby’s head and out of the way. At this point, it’s only the perineal skin ring holding the baby in, if they haven’t already fallen out completely.

3 cardinal things to watch for: color of baby, tone of baby, color of cord (don’t touch, but observe closely).

Choices for women in pregnancy with a breech presentation:

• To try to turn the baby or not? Are we pushing women too strongly to have ECV’s? NO matter how much we think we know, please try not to force women into it. • Positional aids: how to help babies to turn such as lying tilted, knee-chest (this is the only position that’s been well studied)
• Complimentary therapies that may encourage the baby to turn
• ECV

Choices for women on how their baby will be born

• Breech birth. Don’t be overly dogmatic about H&K; women should choose what positions feel right at the time.
• Breech delivery/extraction
• Cesarean Section
• Elective prior to labor
• At start of labor (common practice in Frankfurt clinic)
• During labor when help is needed (Women need to know that a CS at full dilation is more dangerous than pre-labor)

1/3 of all breeches are still undiagnosed, which comprises 1% of all births. All of us practitioners ought to know how to safely birth a breech baby.

Skills required for Practitioners

• Knowledge
• Share experiences
• 2nd practitioner acceptable to woman
• Remind yourself of mechanisms
• Practice with doll & pelvis or torso
• Competent resuscitation skills & appropriate equipment (more often need to do inflation breaths; rare to require more)
• Ability to drink tea intelligently (watch, but don’t interfere. Keep fear and panic out of the room).

If you see anything unusual, put a flag up in your head.

Q: What do you do during the pushing stage?
A: No Valsalva maneuver. Wait until the woman is ready to push. Don’t encourage early pushing; don’t delay inevitable pushing.

Q: What about epidurals?
A: Epidurals are outside her scope of normal and cause a breech birth to fall into obstetrics rather than midwifery. Epidurals interfere with the intricacies of the cardinal movements and pelvic floor maneuvers. That’s why she prefers land births for breeches, since the water pressure interferes with the mechanisms.

Q: What about babies who come down on the left side rather than right? 
A: Let them do their own rotations. However, you are more likely to need to help an arm out. It doesn’t matter which one you help out first, as long as you get one out.

Q: Average length of labor?
A: No answer—it depends on mother and baby. As long as there’s good progress.

Q: What about posterior breeches?
A: Jane and Anke Reitter both agree that the H&K position is key to helping posterior babies rotate appropriately without intervening. This is a very difficult, dangerous scenario when a woman is on her back.

Jane Evans concluded with two quotes:

“The art of waiting on is a difficult one, and not many obstetricians have either the courage or the patience to sit idly by whilst the breech delivers spontaneously.” Plentl AA, Stone RE, Obstet Gynecol Survey 8.3 (1953): 313.

"Caesarean section cannot be the response to suboptimal care for vaginal breech birth." Benna Waites, author of Breech Birth. 

If you don’t feel experienced enough with breech birth, don’t push yourself.

For more information, see:

• Jane Evans. Understanding physiological breech birth. MIDIRS 2.3 (Feb 2012).
• Jane Evans. The final piece of the breech birth jigsaw? MIDIRS 3.3 (Mar 2012).

.

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Optimal Care in Childbirth

I'm really excited to review Henci Goer and Amy Romano's new book Optimal Care in Childbirth: The Case For a Physiological Approach. In fact, I've put off writing about some other exciting developments in order to finish this review.

I've read through the whole book once and skimmed through many chapters a second time. That's no small feat, considering the book is a hefty 583 pages with small font.

Optimal Care in Childbirth is an outgrowth of Goer's two earlier books that made sense of maternity care research and obstetric practices: Obstetric Myths Versus Research Realities: A Guide to the Medical Literature (1995) and The Thinking Woman's Guide to a Better Birth (1999). Henci Goer has been a medical writer, speaker, and consumer educator for the past few decades. Amy Romano is a nurse-midwife with clinical experience in both home and hospital settings. She currently works as a consumer advocate with Childbirth Connection.


So what is Optimal Care in Childbirth about? What does it accomplish? And is it worth the investment? My answer is an unqualified yes. Here's why:


Optimal Care in Childbirth is not simply an updated version of Goer's earlier books. It delves deeper into factors driving maternity care, analyzes an expanded body of research studies, and critiques even more forcefully the abundance of poorly designed research and the gap between research and practice  In Goer and Romano's own words, the book examines:

• why the research shows so little benefit for physiologic care and so little harm from medical-model management
• what’s behind the cesarean epidemic
• what the research establishes as optimal care for initiating labor, facilitating labor progress, guarding maternal and fetal safety, birthing the baby, and promoting safety for mother and baby after the birth
• the true, quantified risks of primary cesarean surgery, planned VBAC versus elective repeat cesarean, instrumental vaginal delivery, and regional analgesia
• how the organization of the maternity care system adversely impacts care outcomes

The book begins with three introductory chapters. The first explains the impetus for writing the book. Goer and Romano note that while careful use of technology and obstetric intervention can save mothers and babies, injudicious obstetric practices do "considerable physical and psychological harm to mothers and babies." Their book sets out what optimal maternity care--"the least use of medical intervention that will produce the best outcomes given the individual woman's case"--can and should look like.

The second chapter examines the weaknesses of medical research. Although the rise of evidence-based medicine (EBM) is an improvement over the older GOBSAT (Good Old Boys Sat At Table) model of obstetric decision-making,  EBM has several downfalls. The privileging of randomized controlled trials (RCTs) often means that other kinds of studies are dismissed, even though they contribute important information. RCTs themselves are subject to poor design and flawed interpretation, and systematic reviews are no less immune to bias. Finally, EBM has become an almost inescapable dogma that precludes other ways of knowing and discourages individualization of care. Despite these drawbacks, EBM still holds promise for pointing to maternity care strategies that work to promote minimal harm with maximum benefit. Goer and Romano comb through the research literature, summarizing and clarifying what we do and do know know, explaining what works and what does not.

The third chapter gives readers an orientation to the rest of the book. They present their methods upfront, arguing that transparency is the best antidote to bias.

The rest of Optimal Care in Childbirth tackles the evidence and customs behind the following maternity care practices:

• cesarean sections (including cesarean rates, repeat cesareans, and VBAC)
• facilitating labor progress (induction, progress of labor)
• guarding maternal and fetal safety (fetal monitoring, oral intake in labor, epidurals)
• birthing the baby (second stage practices, instrumental vaginal delivery, fundal pressure, episiotomy)
• promoting safety for mother and baby after the birth (third-stage management, newborn practices)
• optimal practices for a maternity care system (supportive care in labor, midwife-led care, birth centers, and home birth)

Each chapter begins with an analytical essay explaining the historical and cultural influences behind the obstetric practice in question. The essays then summarize the evidence and examine how far evidence strays from practice. These essays are lively, impassioned, and wonderfully humane in tone. One would expect a book summarizing and interpreting medical evidence to be dry reading, but these essays are refreshingly enjoyable. Biting wit and humor intermix with thoughtful analysis and provocative questions.

Following the essays, Goer and Romano provide a concise list of strategies for optimal care based on the evidence. Here's an example of optimal care strategies from the chapter on second stage (pushing) practices:

The following strategies facilitate a physiologic second stage, maximize the chance of spontaneous birth, and minimize the chance of genital, perineal, or pelvic floor injury:

• Encourage non-supine positions. 
• Avoid interventions that restrict movement and position-changes. 
• Make physical props available and encourage position-changes, enlisting labor companions to assist with support, encouragement, and mobility as needed. 
• Encourage women to follow their spontaneous pushing urges. Discourage prolonged breath-holding. 
• If coaching seems prudent, suggest open-glottis techniques rather than prolonged breath-holding. 
• In women laboring with epidural analgesia, await a spontaneous bearing down urge before beginning active pushing efforts. Encourage open-glottis pushing when the urge develops. 
• Use a supportive and encouraging communication style to promote the woman's sense of safety and wellbeing and diminish her fears. 
• Guide the laboring woman in birthing the baby's head gently between contractions.

Finally, each chapter ends with several mini-reviews of the available research. The reviews carefully note inclusion/exclusion criteria, study design and limitations. and clarifying information. The mini-reviews are where you can really dig deeply into the research evidence. Mini reviews are numbered and organized by topic.

I was struck by how difficult it is to design studies that capture the nuances of an intricate physiological process. Despite mountains of research, very few studies measure more than one small element at a time. That is the nature of medical research, but it works poorly for understanding the complex, interconnected nature of human labor and birth. Too often, a study's design guarantees that very little difference will be found between the "control" (usually an intervention) and the "intervention" (sometimes another intervention, other times a physiologic practice such as oral hydration or walking during labor). Isolating one small practice while keeping the overall package of care unchanged usually shows minimal results.

I was amazed at how much information Goer and Romano were able to glean, despite the limitations of obstetric research. Overwhelmingly, the evidence points to the value of doing less--or rather, the value of understanding and supporting the physiological process so that labor and birth can unfold without undue complication or interference. It's not that obstetric technology has no place; it's just that most of the time, that technology could be safely replaced with patience, respect, careful observation, and following the woman's lead. In order to shift to this style of maternity care, we need studies that examine not just one small change at a time, but that compare entire packages or systems of care. Ambulation during labor in a conservative hospital environment might make little difference in the course of a woman's labor. Ambulation in a care setting that encourages mobility, provides a full range of non-pharmaceutical pain relief options, upholds maternal preference and autonomy whenever possible, and discourages routine use of technology is another story.

Optimal Care in Childbirth is a book we cannot do without. Imagine if every maternity care facility--from the busiest tertiary hospital to the smallest home birth practice--adopted all of the strategies for optimal care set out in Goer's and Romano's book. We would have a maternity care system that supports the wants and needs of laboring women, no matter their location or their individual health profile. We would have a system that delivers optimal care--promoting the physiological processes whenever possible and providing obstetric interventions judiciously and appropriately. We would have a system that uses fewer resources, leads to fewer physical and psychological complications, and has healthier, more confident, more satisfied mothers.

~~~~~

Optimal Care in Childbirth is available at www.optimalcareinchildbirth.com and retails for $50. The authors have offered Stand and Deliver readers a special 15% discount and free domestic shipping through October 31st. Use coupon code MOQLM3W8. Also available on Amazon.

Disclosure note: Goer and Romano provided me with a review copy and invited me to participate in a referral program.

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Seminar at the Yoshimura Clinic, Nagoya, Japan

An announcement from Ina May Gaskin:

I would like to announce an exciting opportunity for obstetricians, family physicians, and midwives to attend a seminar to be held in Nagoya, Japan, at the Yoshimura Clinic. This 3-day event will take place on November 12-14, and will be presented by Dr. Takashi Yoshimura, founder of the clinic, which is world-famous for having maintained a very low rate of obstetrical intervention without sacrificing safety of either mother or baby. (The cesarean rate for the clinic is < 5%).

I will be co-presenting with Dr. Yoshimura (whom I met for the first time in March of this year). We found that we have much in common in the ways we consider ideal for helping women prepare for childbirth and how to best use resources to maximize the incidence of physiological birth.

Expert translation (English-Japanese, and vice-versa) will be available throughout the event.

Place: the Yoshimura Clinic, Nagoya, Japan Date: November 12-14, 2010
Charge: US $2,000, which includes hotel and meals
Optional tour date in Tokyo or Kyoto on November 15: US $500
Contact agent Masae Kakizaki at masaek0108@i2planning.org

Ina May Gaskin, CPM
The Farm Midwifery Center
149 Apple Orchard Lane
Summertown, Tennessee 38483 USA
www.rememberthemothers.org
www.inamay.com

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Confidence, competence, and preserving breech birth at home

Just a few days after my review of Karin Ecker's documentary "A Breech in the System," Australian midwife Lisa Barrett posted the story of a breech home birth she attended (watch the birth video here). Both women's stories are remarkably similar. Originally planning to use in-hospital birthing centers, they are told their only option is a planned, pre-labor cesarean when their babies turn breech. Both women go through great lengths to encourage the baby to turn, including an attempt at ECV. Both find encouragement and support from home birth midwives, even though neither one plans a home birth. Both plan a natural breech birth "in the system."

The woman whom Lisa attended had settled on a hospital birth with Lisa attending and supporting her. However, once she went into labor, her plans changed. (Read the story, linked above, for the surprising conclusion.)

I admire Lisa for her generosity in helping this woman at the last minute. In fact, when Dio was breech and I was wondering what I would do, Lisa invited me to come stay and birth with her. I was floored by her offer. At that point, we had not yet met in person, so she only knew me from my online presence. Lisa's the invitation meant so much to me during that time of upheaval and uncertainty. Fortunately, Dio turned vertex and I did not need to consider traveling halfway around the world.

One problem with preserving the art of breech is that of numbers. Very few obstetricians, let alone midwives, have attended a significant number of vaginal breech births. However, a birth attendant needs to be both confident and competent in attending breeches. Confident enough to stay calm, to keep their hands off the breech,  and to know their limits. Competent enough to have seen and dealt with the rare but serious complications of breech birth, in addition to a sufficient volume of "uneventful" physiological breech births.

I feel strongly that we need to preserve not only vaginal breech birth, but also vaginal breech birth at home. In today's obstetric climate, it is often the only place where a woman can avoid a cesarean for breech. And even if she can find an OB willing to attend a breech birth in a hospital, a woman often faces an uphill battle for an undisturbed, peaceful birth. Lisa's client commented on the advantage of giving birth to a breech at home: "Being at home meant we didn’t have to negotiate for a normal physiological birth without intervention – it was assumed because there were no problems." Not all women wanting a vaginal breech birth will chose to do so at home, but losing or outlawing that option would mean a great loss for women's autonomy and their ability to choose what is best for their babies and their bodies.

Lisa's client ended her story with these remarks:

I’m so grateful that I was able to have a natural breech birth without panic or fear. The birth of our daughter was such a fantastic, positive experience and it saddens me to think that women are led to believe that breech birth is always dangerous or even impossible. As a woman in the public hospital system, I became a black sheep because I questioned their policies and their underlying evidence and refused to accept their way as the only way. I was too much trouble and was effectively turned away. The only reason I was able to birth naturally was because I was lucky enough to find a midwife who believed in birth and believed in me and because I have a like-minded husband who supports me. These things don’t necessarily guarantee anyone a birth free from intervention, but they certainly give the birthing woman a say as to what happens to her baby and her body, placing her at the centre of the decision making process – which is exactly where she should be.

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The Six Lamaze Healthy Birth Practices

I am taking the liberty of reposting the entire announcement from Lamaze, written by Amy Romano, here.

Launched in 2004 to summarize the evidence for a healthy, safe, and natural approach to labor and birth care, Lamaze’s Care Practice Papers, have just undergone their second update. Now referred to as  The Six Lamaze Healthy Birth Practices, the latest update incorporates current evidence as well as more clear language that we know will resonate with women more effectively. These papers supplement the video series and handouts launched earlier this summer in partnership with InJoy Birth & Parenting Videos, and are trustworthy resources for women as well as childbirth educators and other birth professionals.

Each of the Healthy Birth Practices is supported by decades of high quality research. I like to think of the practices as “the basic needs of childbearing women.” Some women will need high tech monitoring and intervention to birth safely, but the standard should be care that supports and facilitates the normal physiologic processes, intervening with the safest, most effective, and least disruptive approach only when a medical need arises and with fully informed consent.

Routinely depriving women of The Healthy Birth Practices makes birth unnecessarily difficult, and complications more likely.  Got it? Good.

So here they are! Drumroll, please…

1. Let labor begin on its own - lead author Debby Amis, RN, BSN, CD(DONA), LCCE, FACCE
2. Walk, move around, and change positions throughout labor - lead author Teri Shilling, MS, CD(DONA), IBCLC, LCCE, FACCE
3. Bring a loved one, friend, or doula for continuous support - lead authors Jeanne Green, MT, CD(DONA), LCCE, FACCE, and Barbara A. Hotelling, MSN, CD(DONA), LCCE, FACCE
4. Avoid interventions that are not medically necessary - lead author Judith A. Lothian, RN, PhD, LCCE, FACCE
5. Avoid giving birth on the back and follow the body’s urges to push - lead author Joyce DiFranco, RN, BSN, LCCE, FACCE
6. Keep mother and baby together - it’s best for mother, baby, and breastfeeding - lead author Jeannette Crenshaw, MSN, RN, NEA-BC, IBCLC, LCCE, FACCE

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2006 US Cesarean Rate

The CDC just released its preliminary birth data for 2006. For yet another year, the US cesarean rate has hit a record high at 31.1%. This is a 50% rise over the past decade, and almost a six-fold increase since 1970, when 5.5% of women gave birth via cesarean section.

A 31.1% cesarean rate translates into 1,326,725 surgeries. 1,326,725 women recovering from major abdominal surgery while taking care of a newborn baby.

Let's imagine for a moment that we had a radically different maternity care system that put the basic needs of laboring women first. Even if most women continued to give birth in hospitals, we could do things very differently. What if hospitals implemented changes similar to Michel Odent's maternity clinic in Pithiviers Hospital. These changes were inexpensive and low-tech, including:

• soft, large mattresses--no delivery tables
  
• large, deep birthing pools
• birthing chairs
• cozy and private rooms
• extremely limited use of Pitocin (around 1%) and pain medications
  
• low-profile midwives overseeing births and consulting obstetricians for complicated cases
• mothers encouraged to labor and birth in whatever positions felt most comfortable to them.
• emphasis on creating a private, warm, and safe environment for the mother to labor in
  

Odent's hospital was able to achieve a 6-7% cesarean rate while at the time having one of the lowest neonatal mortality rates in the world. Other hospitals were only able to achieve such low mortality rates via a very high cesarean rate. The Pithiviers clinic served an unselected population; in other words, it didn't weed out unhealthy or "high risk" women and send them to a larger facility. Read more about Odent's clinic in Birth Reborn (pictures below are from the book).

If our country had a 7% cesarean rate, we would only have 298,620 cesarean sections performed each year. More than a million women and babies would avoid major surgery with all of its physical and emotional costs.

A typical French delivery room

Pithivier's new birth rooms
Midwife and laboring woman

Upright, physiological birth
(Michel Odent is supporting the woman's weight
while the midwife waits for the baby to emerge)

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A family doctor's perspective on BOBB

Among members of the audience for The Business of Being Born was a family physician who attends births and her youngest daughter. She emailed me some of her thoughts about the documentary and gave me permission to repost them here. I highly admire her dedication; she works hard to give women hands-off, physiological births in a hospital setting.

Overall, I was impressed with the movie. I tried to look at it with two viewpoints in mind. One, my own sort of "birth junkie" self. Two, I tried to see it as my mostly mainstream clients and acquaintances would.

I was pleased overall with the births they showed, and I loved many of the commentators. I loved that the births were shown to unfold in their own time and that the mamas looked free to move on their own and birthed upright. I love that upright birth center birth where the mama is so joyous right after. I thought Michel Odent was absolutely great. I liked the juxtaposition of the "woman on the street" type comments in between, too--sadly, all those women ready to sign up for their epidural are what I deal with a lot of the time and are very realistic.

It was funny, because looking at the births, I actually thought some were a bit hands-on for my taste. (Why does the midwife have her hands around that woman in the water? What was she trying to do?) On the other hand, I think a mainstream viewer might think they were too "non-medical" especially since Cara can't seem to get gloves on in time ever.

I cried at every one of those births. Don't know what was up with that! My little dd even kept asking me if I was okay. (I cry a fair amount of the time at actual births, though, too--you'd think I'd get over it.) I think if people watched this movie and the only thing they took away was visions of women pushing their babies out standing, squatting, in the water, whatever, that would at least be a start. I find that I have to talk quite a bit during prenatal care about how women should try out different positions ahead of time and see what feels comfortable to them, and how we will be encouraging them to move any way they feel comfortable during labor and pushing. Sometimes family members especially are just shocked when the birthing woman ends up standing or squatting or kneeling. Sometimes I think they then think I'm a little nutty or not very professional, because I "let" this go on. Fortunately, usually the birthing woman herself can verbalize how being free to choose her position made her feel better, or that it was more effective for pushing, or whatever.

I was disappointed in the ending. I don't think they explained enough what was happening, and I was disappointed that the final interview blew off any benefits of homebirth and implied that it's all nice if you can have it, but thank God we had this cesarean and saved my baby. I actually think in her particular case transferring for a breech, growth-restricted baby was probably a good idea--but there had to have been a better way to wrap up that movie than Abby saying "Oh well, at least I got a healthy baby" you know?

I wish they'd wrapped up with some kind of activism information--like talking about CIMS, or ICAN. Here's where you can start to change the world kind of info.

The discussion after was really something. It was interesting to hear people's stories and encouraging to hear so many women who think this stuff matters. It was also discouraging, though, to hear how people struggle to get the birth they want. I am pretty disappointed in this whole VBAC thing, and disappointed especially that so many "low-risk" providers are just giving up VBACs and verbalizing that it's just too bad, so sad for the women involved, but nothing we can do. The midwife who talked expressed similar feelings to what I've been hearing from other family docs: "Oh well, we just can't because of these rules." I feel like so many birthing women basically can only have midwifery, or at least woman-centered physician care, if they are low risk, don't have any problems or inconvenient history, and do what the low-risk provider wants. Otherwise, you are stuck in the OB system and have to take the full court press. It's just not fair and I can't figure out how to fight it. Especially in this stupid state. I wish women like that woman who had an episiotomy against her will would make complaints--take it to the hospital administration, the chief of medical staff, and the medical board for failure to get informed consent. I know one complaint is not likely to do anything, but if there were more and more, I think hospitals and regulatory boards would have to listen. It is not okay that thousands of women are treated as if their wishes don't matter one bit routinely in the name of "standard of care."

I actually think all of medicine needs to be reworked. Something I was trying to say, and may not have got it out coherently at the panel discusson, is that having doctors in charge of medical care and responsible for the outcomes doesn't benefit anybody. If birthing women were in charge, in power, and responsible for decision making (not really so much the outcome, because there is so much that is up to chance), I think they would be more satisfied--AND doctors maybe could relax some. Because I think if we stopped this patriarchal, authoritarian way of practicing medicine there would be far fewer lawsuits. If every woman got actual informed consent AND had the opportunity to make her own decisions and then got supportive care when they needed/wanted it, they would be far less likely to sue. (I just went through a long involved discussion with a new client about VBAC and feel I gave her a good understanding of the risks either way, but she is really stuck in that no one in driving distance who takes her insurance does VBACs anymore--doesn't matter how informed you are if your options are so limited.) As a profession, though, we docs don't want to give up the power. We want to be in charge, want to be seen as demi-gods often, and don't want to present our selves as fallible humans doing the best we can with the knowledge we have and freely sharing that knowledge with our clients.

I'm not sure how to make a change in modern obstetrics, but I think one factor is that women have to refuse to accept paternalistic, condescending care. I don't care what kind of choices women make, but they need to insist on accurate information and fully informed decision making.

OBs need to get out of the business of normal maternity care. We have put normal care into the hands of folks trained in the abnormal. You know the saying, “if the only tool you have is a hammer, everything looks like a nail?” If you are looking for trouble, you generally find it one way or the other. Somehow, we have to get in through our heads that women's bodies have not changed that much in the last 30 years, so if the cesarean rate has sextuptled (and it has!), something must have changed in doctors. I'd like to see more consumer-driven organizations getting more and more active and making more of a mainstream presence. I mean, how many women even know there is something like ICAN or CIMS?

The problem, too, is that it seems that as a whole group, women may not care that much about birth. I wish this was more of a feminist issue--I don't understand why women are willing to be condescended to in this area and have choices taken from them. Have you ever read Barbara Katz Rothman? She is a feminist writer who has done a lot of work on birth politics and talks about how she talked an OB into attending her first home birth by basically appealing to the female OB on a feminist basis. (The book is In Labor: Women and Power in the Birthplace.) I just don't see that happening any more. I went into medicine out of a desire to provide woman-centered care from a background of feminist ethics. I feel more and more out of place in modern medicine every year--my colleagues think I'm sort of nuts, my family suffers from me not being there, and even many of my clients don't seem to care much about having the chance to direct their own care.

I wish I could have come to the rest of the discussion. Did you all come up with any way to change the world?

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